TrumpRX Pricing Changes Changed Our IVF Protocols: Here is Why

Watch this (Season 3, Episode 19) on Youtube or listen on your favorite podcast platform to Two Peaks in a Pod.

Dr. Beverly Reed and Dr. Amber Klimczak discuss how the TrumpRX dramatic price drops for IVF Medications has them rethinking the best strategies on how to make IVF medications affordable and effective. They discuss that low dose HCG may be an increasingly used option that has many benefits including lower pricing.

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Two Peaks in a Pod

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#fertility #womenshealth #ivf #hormones #lowdosehcg

Transcript

Speaker 0:05

Hi, I am Dr. Beverly Reed.

Speaker 2 0:07

And I'm Dr. Amber Klimtzak.

Speaker 0:09

And we are two peeps in a pod.

Speaker 2 0:10

Two peeps in

Speaker 0:10

a pod. That, well, welcome back, everybody. How's your week going?

Speaker 2 0:14

It's good. It's a rainy week. It's kind of depressing.

Speaker 0:16

I know. It is gloomy. I'm, uh, actually we should turn our light on. Yeah. Yeah. Bring it

Speaker 2 0:19

back. Yeah. There we go. Okay. There we go. Okay. We're a little bit brighter now. Yeah.

Speaker 0:22

Yeah. Um, okay. Well, I thought today would be a good idea to talk about the changes that we've had with fertility medications this year. But also before we even get into that, gosh, everything keeps changing every week this year, and I kind of love it. I love change.

Speaker 2 0:41

Mm.

Speaker 0:42

We... Remember how they changed how we diagnose endometriosis? Yes. Then they changed the name of PCOS.

Speaker 2 0:48

Ugh. Huge.

Speaker 0:50

They've changed all the pricing on fertility medications. Mm. Like, this is a happening year- Yes for fertility.

Speaker 2 0:54

Yes. I feel like this episode is really up your alley, 'cause I know that you- Yes like a good deal. Like- Oh, my

Speaker 1:00

gosh

Speaker 2 1:00

um-

Speaker 1:00

Always

Speaker 2 1:01

tell our listeners about your, what is it, the- the Walmart Birkin.

Speaker 1:06

Yes. Actually, maybe we should just, like... You wanna grab it? Yeah. Yeah. Okay. The girls were laughing because if you guys know me- Mm-hmm I get everything off of TikTok Shop. Okay? I thought this was just, like, a cute little purse. Okay? And I didn't know that this is a Workin. Mm. Okay? Now, it's supposed to look like a Birkin. A Birkin's a very fancy purse. I wouldn't know about these things. Um, but a Birkin is, uh, like $30,000- Oh, yeah or something like that. Easily. Yeah. Okay. Um, and so of course I'm not gonna spend that on a purse. Um, and so this was on TikTok Shop for... I feel like I should have a link. Maybe I should be, like, one of those influence. Um, but I got this purse and they call it a Workin, which means, like, a Walmart version of a Birkin.

Speaker 2 1:49

Love it. Yeah.

Speaker 1:50

So anyways, yes. I am always out for a deal. Mm. I, um, always want to get the best price that you can get. Um, I feel like I got it from my mom and my nana. Mm-hmm. Like, when we were little, we were looking for the sale. Yeah.

Speaker 2 2:02

Yeah.

Speaker 2:03

You know? I, like, when I start, started learning math, it was all about percentages. Like, 20% off. Let me do that calculation- Mm. Yeah in my head, you know? Um, and so I will say that is why I'm really, really excited about all these changes. I also have to give a shout-out to Nurse Julie. She's one of our nurses and- She and I have been working together for years. A- actually, every single place I've worked at, UT Southwestern, I worked with Nurse Julie. Mm-hmm. Um, my prior clinic, IVFMD, I worked with Nurse Julie. Now she works with us here at Peak. And Julie also loves a good deal, and she puts the work in. Yeah. So for our patients, everywhere I worked, she would call around to all the pharmacies, and she would say, "Look, give me your best prices." And she wasn't doing this intentionally at first, but the pharmacies started trying to negotiate essentially. Yeah. And she would say, "Okay. Well, pharmacy number one will give us this price. Pharmacy number two has a cheaper price." Well, then pharmacy number one will say, "Well, wait a second." Yeah. "We'll, we'll give you guys this lower price." Mm. And before you know it, our prices were so much better than what the patients were having to pay before. And so I've always really appreciated that she put the work in for our patients. Um, and she continues to do it, too. She tells the pharmacies, "Look, we're not loyal to anybody."

Speaker 2 3:16

Right.

Speaker 3:16

We're loyal to- Yeah our patients."

Speaker 2 3:18

Yes.

Speaker 3:18

Yeah. So although we may use a certain pharmacy, we will change any day of the week if we get a good deal for-

Speaker 2 3:24

Yeah for our patients. And I think that a lot of my patients are very cost savvy, too.

Speaker 3:28

Yeah.

Speaker 2 3:29

And periodically, I do have patients that shop around. Mm-hmm. Yeah. Um, and they tend to come back and say- Yeah "Note to you guys, you were right. This is the cheapest pharmacy." Yes. So we do try and always shift towards the cheapest availability.

Speaker 3:40

Yeah, because it's all the same medication anyway,

Speaker 2 3:42

right? We do not care- Yeah where you get your meds from.

Speaker 3:44

Yeah, yeah. Yeah. So usually we talk about a celebrity, but this, this celebrity I feel like is a little controversial- and I hate to talk about cr- con- controversial things. Mm-hmm. In fact, I hate to talk about politics at all. Yeah. I... It's so uncomfortable, but you can't not talk about it this year, which is the emergence of Trump Rx- Yes which was a website or is a website where you can go on and get certain medications for much cheaper. And you know, I think this had been promised on the campaign, but I think many of us always feel like, oh, you hear these promises, but does it- Yeah ever happen?

Speaker 2 4:17

Yeah.

Speaker 4:18

Because we had done so much negotiation with pharmacies in the past, we had always been told the same thing, which is, "We just can't get the prices any lower." If... So remember how we even talked about what if we had our own pharmacy? Yeah. Could we get the meds cheaper for our patients or something? And we just kept hearing the same thing. There's no markup on these medications. Mm-hmm. It's impossible for them to be any cheaper. And we kind of, we just believed it. We were like,

Speaker 2 4:43

Okay." Yeah.

Speaker 4:43

And then suddenly, here comes Trump Rx, right? And so they say, "Look, if you get these medications, now they're dramatically cheaper." And then all of the sudden, all those pharmacies started reaching out to us, "Oh, by the way, we also cut our prices dramatically."

Speaker 2 5:00

Yeah. Yeah. So what Dr. Reed is saying is there's different brands of fertility medications that are exactly equivalent, right? And it's just like taking, um, a medication by a brand name versus a different brand name. What's the active ingredient? It's ibuprofen or it's acetaminophen, right? They can go by multiple different brand names. But basically, Trump Rx had one brand name medication, and they agreed to lower this price. And then all of a sudden, the other ones had to follow suit. And so that really made a big impact to the, to the fertility world.

Speaker 5:37

Yes. Yeah. And that was kind of interesting when that first happened because at first people thought, "Oh my gosh, if I wanna get the good prices, I have to go through Trump X- Mm-hmm uh, Trump Rx," and I thought that too. Mm.

Speaker 2 5:48

Same. Yeah.

Speaker 5:49

But then as soon as all the other pharmacies followed suit, and really they had to because if not, they were gonna go out of business, right? Mm-hmm. Um, why would anybody pay twice the price if they could get it through Trump Rx? So immediately, all the other prices dropped on these medications. And so we can still use a different brand name than what's on Trump Rx and now essentially have the same cost- Right which is amazing.

Speaker 2 6:13

Yes. Yeah. Huge breakthrough. I mean- Yeah just overall, I mean, in our estimates, this is dropping the cost of your overall IVF cycle sometimes by $2,000. Yeah. That's a lot of money.

Speaker 6:22

Absolutely. Absolutely. Um, and so whenever this happened though, it really kind of opened our eyes as to maybe different recipes or protocols we could be using because some of the brand name medications had price cuts, but others did not. So the ones that we were seeing that had big price drops were Follistim and Gonal-F. Those are... I would call them the twins, right? Right. You could use either brand name- Mm-hmm but they would have similar effect. This is a medication meant to mimic FSH stimulation of the ovaries. But one of the other medications, Menopur, I don't think it really decreased in price. And I mean, did it increase in price even?

Speaker 2 7:00

Yeah. It d- I don't I haven't seen a difference with it.

Speaker 7:02

Yeah. Okay.

Speaker 2 7:02

Yeah.

Speaker 7:03

Yeah. So not seeing the price drop there, um, made us kind of reevaluate some of the options in terms of being strategic with financial, um, just planning. And so a traditional IVF cycle for most fertility doctors involves using either Follistim or Gonal-F, which is made to look at or to... made to look like FSH, plus another medication that has both FSH and LH effect in it. And most people are familiar with the brand name of Menopur. So if you're using both of those and one of the medications became way cheaper and the other one is about the same, you do kind of wonder, "Hmm, is there anything we can do about that?" So do you wanna talk about how you have some experience with an alternative from the prior place that you used to work at and-

Speaker 2 7:53

Yeah. Yeah and what we can do. So I would say across the country, really for a long time, there's been many IVF centers that have been utilizing a different LH component compared to Menopur. So we know in order to get your follicles to grow, we basically need those two ingredients, FSH and LH. They're hormones that come from your pituitary gland, and we're trying to give you a lot of them to convince your ovaries to grow a lot of follicles. And so we can get that LH component from Menopur or we can get that LH component from low-dose HCG or just HCG in general. A lot of patients have heard of HCG. It's used as a trigger shot, right? It's gonna bind to the receptor the same way the LH component in Menopur does, and it's going to give us that same activity and stimulant we need on the follicles. The nice thing about low-dose HCG is you need a really small amount of it. It's compounded from a pharmacy, which makes it way less expensive compared to brand name Menopur. And what we do is we increase your dose of those cheaper medications like Gonal-F and Follistim because we need to get all of your FSH component from that because low-dose HCG does, does not have any fo- um, FSH component. And then we just give you the LH with the low-dose HCG. So we're basically giving you all of your ingredients, just with a slightly different recipe Um, this has been around for a really long time. This really is not something novel. We're not making a breakthrough on medication dosing. This is how I trained. I would say 50% of our cycles were done with this recipe. Um, very similar in efficacy. Don't have any concerns that one works better than the other. Just like all fertility medications, I will say maybe there's some patients that do better with one versus the other. Mm-hmm. Hard to predict who that's gonna be- Mm-hmm until you actually go through it.

Speaker 9:35

Mm-hmm.

Speaker 2 9:35

Um, but that recipe has allowed us to lower the cost- Mm-hmm for our patients. Probably the number one benefit- Mm-hmm is cost lowering.

Speaker 9:44

Yeah.

Speaker 2 9:44

Which is extremely important.

Speaker 9:46

Yeah.

Speaker 2 9:46

Yeah. And we're telling you, as fertility doctors that have looked at the data and the studies, it's exactly the same. Mm-hmm. We really don't see any difference-

Speaker 9:52

Mm-hmm

Speaker 2 9:53

um, in outcomes. And so why not go with the cheaper recipe, right?

Speaker 9:56

Yeah. Right. Right. Well, I loved that you had had so much experience with it before at your prior clinic. I think sometimes as doctors, we're just more hesitant to do something different than- Mm-hmm what we're used to, right? Mm-hmm. So I really got to lean on your experience there to have the reassurance that it's similar. And now we've both been using it in, in patients, and it does seem to be working better. Well, not better, equivalent. But here's why I think it might be better, is I have a nickname for Menopur. I f- I hope nobody from Menopur is watching this. They're gonna be mad.

Speaker 2 10:26

Yeah.

Speaker 10:26

But I call it MenaBurn.

Speaker 2 10:28

Yes.

Speaker 10:28

Actually, I did get this from TikTok. I didn't make this up. Yeah. Because here's the thing, when patients take the Menopur injection, oftentimes it will burn. And they don't get that from Follistim or Gonal-F- Mm-hmm usually, right? And so my patients would tell me, and I would then tell, um, one of the reps at, uh, Menopur and they, one of the reps told me, "No, I've never heard that."

Speaker 2 10:48

Yeah.

Speaker 10:49

Right. And I'm like, "What?" Right. And I'm like, "Just look on social media." Like, try

Speaker 2 10:52

out your product.

Speaker 10:53

If you look it up, you'll see all these patients on social media like, "Ah, it's burning," right? And the reason I was telling them, I was, I'm like, "Can you make it better? I don't know- Hm if it can be made better, but can you make it better?" Um, and so I have found in comparison, um, if you're using that compounded low-dose HCG, that patients report, um, that there's no burning- Mm-hmm associated with that as well. Are you hearing the same thing

Speaker 2 11:16

from your patients? Yeah. Yeah, definitely. Okay. And the other, I think, intimidating aspect of doing IVF in general is you are having to give yourself injections. But probably the most intimidating injection that we've been using is Menopur. Mm-hmm. Because Menopur has to be mixed- Mm-hmm and you have to do it every day. Mm-hmm. And it's not just mixing one vial. Most of our patients are doing multiple vials of Menopur. So you're mixing the vial and then you're putting it into another vial. I think it's the most complex of all of our medications to administer, right?

Speaker 11:41

Yes. Mm-hmm. And I've definitely seen some confusion with this- Mm because sometimes we've tried to teach patients how they can give essentially a lower volume Menopur injection- Mm-hmm um, when they're mixing vials, but it does become more complex. Yeah. And it can feel really overwhelming for patients. And so the dosing of the low-dose HCG is really just as simple as, okay, you're gonna drop 10 units or 20 units- Mm-hmm or however many. It's already mixed up and ready to go. I do think, though, that this is not, you know, personal medical advice for you guys. You always need to check with your doctor and make sure you're also working with a pharmacy that you trust. Mm-hmm. Our pharmacy that we use has been doing this for many years. They're very precise and, and all of that. Because sometimes, um, what you will hear from these big drug companies is, "Well, our medication was made in this factory and has all this, you know, special testing." And when you're using a compounded medication, you may, um... It's almost viewed as inferior in some ways. Um, but in the fertility world, it's very common to use compounded medications. Mm-hmm. We've been uni- using it for many years. And if you are working with a pharmacy that is trustworthy and you've seen the results for many years, I think you have more trust in that situation. But if your doctor doesn't have a pharmacy that they feel is trustworthy, you might be in a different situation when looking at those options too.

Speaker 2 12:53

Right. Absolutely. Mm-hmm. And you're gonna feel the benefit of lowering of those other medications, Gonal-F and Follistim, as well. And we're just suggesting that when you convert- Yeah this way, you get even more of a price decrease.

Speaker 13:04

Yeah. So I think what is tricky is the conversion, though. Mm-hmm. Because, um, because the Menopur has both FSH and LH in it- If, and when I say LH, LH effect I should say. Um, if you're gonna replace the Menopur with low dose hCG, which only has the LH effect, then you're gonna have to increase the amount of the Follistim or the Gonal-F that you're giving. So let's maybe run through an example. So let's say I have a protocol where I wanted the patient to take Follistim or Gonal-F 150 units and 75 units of Menopur, which is one vial. Well, if I were gonna convert that to a low dose, um, hCG cycle, then instead of the one vial of Menopur, I would say take 10 units of the low dose hCG. But then because there's no FSH in that, I've got to increase my Follistim or Gonal-F to 225 units. Yeah. Okay? And so that can feel really confusing, 'cause when we've done that, haven't some of your patients said- Yeah, so I've

Speaker 2 14:10

had- "Oh my

Speaker 14:11

gosh, you're increasing my dose"

Speaker 2 14:12

we- right. We've just- kind of transitioned to this. So I've had some patients that did an IVF cycle a couple months ago-

Speaker 14:17

Yeah

Speaker 2 14:18

and used Menopur- Yeah and then now they're cycling with me again. They're like, "Why are you dosing me so high this time?" Yeah. I'm like, "I'm not. I'm actually dosing you the exact same."

Speaker 14:25

Mm-hmm.

Speaker 2 14:25

It's equivalent dosage. So, um, I can definitely see how that's confusing. But for example, if your dose was 300 of Follistim and two vials of Menopur, now your dose might be 450 of Follistim- Mm-hmm and just your low-dose HCG. Yeah. So it certainly can be, um, tricky. Another kind of just interesting detail that I noticed when we use these protocols a lot, um, when I was up in the Northeast, is a lot of us doctors like to adjust- Mm-hmm the LH component- Yes and the stim. Yeah. And so I will say this is another benefit of low-dose HCG. Mm-hmm. And my co-fellow and I, we call ourselves tinkerers. Dr. Relleke-

Speaker 15:00

Oh, tinkerers and I,

Speaker 2 15:01

we like to tinker, right?

Speaker 15:02

I like that. Okay, good.

Speaker 2 15:03

We're always tinkering- Yes with our cycles, right? Yes. And so I definitely think you can tinker more- Yeah when you have low-dose HCG. Yeah. So if we don't like the way some of your hormone values are looking during your stimulation- Mm-hmm we can adjust your low dose and, and correct those quite a bit. Mm-hmm. Um, it's harder to do- Mm-hmm when you're on Menopur.

Speaker 15:19

Mm-hmm.

Speaker 2 15:19

So there are some other behind-the-scenes, uh, benefits that your doctor might be doing if you're on low-dose HCG.

Speaker 15:24

Yeah, yeah. And then, um, just to give you a ballpark figure, this low-dose HCG, um, and of course it will vary from pharmacy, pharmacy to pharmacy, is roughly about $100 for the vial that lasts you the whole cycle. Um, and so you could even say, "Well, gosh, why weren't you using that, you know, last year or something?" And again, some people were, but in our case, the math wasn't making sense because, yes, we would get the lower, um, priced low-dose HCG, but then we had to buy more of the Follistim or Gonal-f, which at that time was so expensive that it ended up just being a wash. Right. And so that's why we weren't doing it back then. But the other thing is you will see me still ordering Menopur for some of my patients, and the reason for it is a lot of my patients are fortunate enough to have insurance coverage. And insurance is a little picky about what you can order- Mm-hmm in terms of brand names for patients.

Speaker 2 16:13

Mm-hmm.

Speaker 16:13

And so I thought we should kind of maybe talk through that, walk through that, because some patients may not have great guidance on how insurance coverage can be great, but you also wanna make sure that you're still getting the best deal even when you've got insurance coverage.

Speaker 2 16:26

Yes. Yeah. Yeah. And so, I mean, the concept is I think most people can understand this. If you've taken any prescription medication in your lifetime, you've probably gone to the pharmacy and they've said, "Well, that's not on your formulary" You have to go and get this other medication because your insurance carrier has basically a deal- Yeah with, with that medication formulary. So then you switch over to that other one, right? Mm-hmm. Same thing for fertility medications. Mm-hmm. Your carrier has worked out that they want you to be on this particular type of fertility medication brand name, right? Yeah. We're telling you probably the same efficacy, but brand name-wise. So really important, what you should always do any time you get your fertility medication order, check the cost. Mm-hmm. Check and see what they're billing your insurance. Check and see what you're gonna pay out-of-pocket, and you might wanna compare that to what would you pay out-of-pocket if you were completely going self-pay and not utilizing your insurance at all. Sometimes it's not worth it.

Speaker 17:18

Exactly.

Speaker 2 17:19

Definitely seen situations where patients are paying $6,000 out-of-pocket for their fertility medications. Mm-hmm. Or they're billing astronomical amounts towards your fertility benefits, eating away all of your fertility benefits, you have nothing left. Yeah. So you really wanna be savvy here. Always check your cost estimate. Check and make sure before you give them any payment information what you're gonna owe out-of-pocket and what's getting billed towards your insurance.

Speaker 17:43

Yes, that is great advice. And, you know, sometimes your fertility clinic may help you with this, but sometimes it's so complex that even fertility clinics may not have a good grasp on it. And so here's some homework you can even do yourself, which is call your insurance company and ask them for fertility, number one, do I have coverage for fertility medication? Number two, do you have a preferred pharmacy? If you have coverage, they almost always have a preferred pharmacy. So do you have a preferred pharmacy that, um, we need to go through? Number three, do I need a prior auth done? If so, make sure you get your medications ordered really early 'cause prior authorizations take a long time- Mm, mm-hmm to come through sometimes, okay? Then you can ask them, and they may not know, but you can say, "Are there any preferred brand names?" Now, if they don't know, usually the pharmacy will know, okay? And then another important question is, how does my benefit work? So for some people, they have a total fertility benefit that they can use to cover the cost of medications and treatment, and it's all combined. So for example, let's say they say, "Well, you have $25,000 of fertility benefit, and that does include the cost of your medication." Okay, that's really helpful for you to know because what's tricky is I've seen before where the patient goes to use her benefit- Let's say she's using... Well, maybe I shouldn't use a pharmacy. Mm-hmm. I won't name a pharmacy. Mm. But she calls her preferred pharmacy, and the pharmacy says, "Okay, you've gotta pay $50 copay. We're gonna send you these medications." She says, "Great. I get all these medications for a $50 copay." Okay. But what they didn't tell her is, "Yes, but that used $11,000 of your fertility benefit." What? That's crazy. You and I both know those medications don't cost that.

Speaker 2 19:36

Mm-hmm.

Speaker 19:36

And this is where I don't understand. Insurance can be very scammy.

Speaker 2 19:39

Yeah.

Speaker 19:40

And so that's a good question to ask, "Okay, what's my copay?" But also, what are you charging my insurance, right? Mm-hmm. And if they're charging your insurance $11,000 when we know these medications should at most cost maybe $2,600, then that's your stopping point to say, "Wait a second, I may decide to self-pay for my meds so that I can preserve all that other benefit to help me pay for my fertility treatment." Now, for some people, their insurance is set up differently. For some people, they'll say, "Okay, you've got $20,000 to use towards your fertility treatment, and you have $5,000 to use towards your medication benefit." Okay, well, that's a different situation, right? But in that case, again, let's say you call the pharmacy and they say, "Well, you have $5,000 of benefit," and your bill is 11,000. Okay, again, maybe don't use that whole benefit. Mm-hmm. Say, "Okay, I'll take my 5,000 of meds- Mm-hmm and I'll just buy whatever I need left over-

Speaker 2 20:33

Yeah

Speaker 20:33

self-pay with cash 'cause it'll be cheaper that way," right? So it's tricky, right? That's a lot of homework to do as a fertility patient.

Speaker 2 20:40

It is. Yeah. It definitely is. Yeah. But I think it's helpful to know this-

Speaker 20:44

Mm-hmm

Speaker 2 20:45

in advance.

Speaker 20:46

Yes. Right?

Speaker 2 20:47

Just come armed with information. Yeah. Um, you know, not a, not all, um, you know, insurance companies are really on your side, right? Yeah. So I know they can have patient advocates- Mm-hmm and things like that, but sometimes, you know, they're not looking out for what's best for the patient.

Speaker 21:02

Yeah. And if anybody wants to reach out and explain it to me, I would love to know. 'Cause to me, I'm also like, okay, why would the insurance pay $11,000 for meds that we know you can get for 2,600?

Speaker 2 21:12

Mm-hmm.

Speaker 21:13

Why would they even be doing that to start with? I feel like there has to be something scammy going on- Yeah that we don't know about.

Speaker 2 21:18

Yeah. Right? I mean, my understanding is they have contracts where they're, you know, we agree to only use this medication- Mm-hmm and funnel this money to you- Mm-hmm from our patients that are paying them money for their insurance, right?

Speaker 21:29

Mm-hmm. Yeah.

Speaker 2 21:30

So-

Speaker 21:30

Mm-hmm

Speaker 2 21:30

very questionable.

Speaker 21:31

Yeah, yeah. Um, okay, so we've mainly been talking about IVF stimulation medication. Mm-hmm. Um, but I do feel like when we're talking about hCG, it can be very confusing. So should we also just talk about some other ways that hCG is used and just kind of specify that, you know, in this case we're using it for stimulation, but can you tell us about the other

Speaker 2 21:54

uses?

Speaker 21:54

Right.

Speaker 2 21:54

Yeah. So, um, hCG, probably the most common time you've heard about it if you're a fertility patient is we use it for, as a trigger shot. It's the main ingredient in your trigger shot, which forces ovulation to occur at a specific time. And this is another example of cost savings. If you're one of our patients, you might have noticed that we transitioned from having a brand name hCG trigger shot over to a compounded trigger shot, um, just for affordability. And so same sort of thing, you can have this higher dose of hCG that can be a brand name, it's slightly more expensive, or compounded. It's a different amount of that hCG in a trigger shot versus what you're doing when you're doing IVF stimulation. IVF stimulation is way less concentrated. Mm-hmm. You need very low amounts, that's why it's called low dose hCG, compared to this higher dose of hCG that you'll trigger with. So also don't get confused. If you have done a, um, IUI cycle or a medicated cycle and you have some trigger shot left over, that is not- Mm-hmm the same thing as your low-dose hCG. You can- Mm-hmm really mess up a cycle using the wrong concentration.

Speaker 22:56

Yes.

Speaker 2 22:57

So make sure you talk to your doctor. Don't try and re- reuse your meds. The other common time that patients are using low-dose hCG usually is male patients will use this who, um, have, um, low testosterone, low sperm counts, things like that, and they can do weekly or twice weekly injections as opposed to using testosterone, which can shut down sperm production. So a lot of men will use it for that.

Speaker 23:18

Yeah, yeah. And I guess maybe a couple of other things to think about when we're talking about hCG is I just love to think about why does it even work? Um, and so we've got these receptors, of course, in our body, and usually in nature, we're often talking about LH, that chemical that comes from your pituitary gland that talks to your ovaries. And so if you have a little bit of LH every single day, that's kind of what is joining up with FSH to help your follicles to grow, but when you get a big surge in your LH, that is what induces ovulation to occur. That's why it's so important to get the right dosing and concentration. And so what I think is fascinating is LH and hCG, which is pregnancy hormone, both bind to the same receptor. But LH has a shorter half-life in your body. It disappears faster, whereas hCG stays in, in your body longer. Because of course you could ask, "Well, why don't you just give LH?" Actually, 'cause notice how we were saying LH versus LH effect, right? Mm-hmm. So you don't usually give LH because it disappears so fast. Um, H- or hCG is nice because it produces the same effect and it lasts in the system longer. And in fact, if you are taking it and you take a pregnancy test, it's gonna turn up positive, right? Yes. Um, but with the low-dose hCG, if you check your levels, your hCG level in your blood would probably be about, like, three or four or something like that. Whereas if you're taking a trigger injection and you check your level, it's probably gonna be about one- 100, maybe 150 or something like that, depending on the dose that you give as well. So I just think it's interesting to think about why you can use that in either circumstance as well.

Speaker 2 25:02

Absolutely.

Speaker 25:03

Then I also just wanted to touch on another medication substitution that we've been doing sometimes as well. So once patients end up in the embryo transfer stage, there is a subset of patients that sometimes need to undergo hormone suppression. So this is usually for people who've been trying embryo transfers and they're not working, or sometimes with patients with a diagnosis of endometriosis and/or adenomyosis. But the concept is you need to put the body into temporary menopause, and we usually accomplish this with a medication called Depo-Lupron, which is one shot per month for two months, and then letrozole pills. You take one pill twice a day for two months. But the letrozole tends to be pretty affordable- Mm-hmm and oftentimes is covered by insurance. But that Depo-Lupron is expensive. Yes,

Speaker 2 25:53

always been expensive.

Speaker 25:54

Oh

Speaker 2 25:55

my gosh. It's weird. I remember back even being in medical school learning- Yeah about Depo-Lupron for things. Yeah. And they were like, "Oh, well, you know, hardly any patients can afford it." Yes. I know, it's so pricey.

Speaker 26:04

Yeah. So I mean, I heard the other day, um, one patient was getting quoted $3,000- Crazy. Yeah for one shot. What? So that's so crazy. Um, so in years past, of course we always try to get it approved by insurance first I will say being able to use the new diagnosis of endometriosis has really helped. A lot of times if you code it as endometriosis, if they're having painful periods, uh, pain during intercourse, you suspect or see endometriosis on an ultrasound, um, if you can code the Depo-Lupron as that way, uh, most of the time it is covered.

Speaker 2 26:39

Mm-hmm.

Speaker 26:40

So that's been nice. Um, adenomyosis, I haven't typically been seeing that as covered. Have you?

Speaker 2 26:45

I'm, I'm, I'm usually not using it just for patients- Okay that have adeno.

Speaker 26:49

Yeah. Okay.

Speaker 2 26:50

So, yeah.

Speaker 26:50

Um, and then, um, so, so I think the good news is more people are getting it covered. Um, it does often require a prior authorization, so again, you kind of wanna be doing that ahead of time. Um, but for the patients who are not getting it covered, um, you know, in the past sometimes they were even... I hear, we can't recommend this, but I hear sometimes they were getting it from Canada.

Speaker 2 27:12

Okay.

Speaker 27:13

Um, because... And that's not fair. Apparently it was much cheaper in Canada.

Speaker 2 27:17

Yeah.

Speaker 27:17

Um, but-

Speaker 2 27:18

Hello, Trump RX. Yes.

Speaker 27:20

That's right. I know, actually, and this is where I'm really hoping the price of Depo-Lupron- Mm I, 'cause I've been checking. Mm. And Depo-Lupron pricing has not come down yet. But apparently there's a new policy, it's called a favored- Mm nation policy- Yes. Yeah or something like that, where they're not gonna be allowed to sell the medication for any cheaper than what the US can have- Mm-hmm access to. Yeah. So I think once that takes effect, hopefully this will not even- Mm-hmm be an issue anymore. Um, but in the meantime, if I have a patient who wants Depo-Lupron, it's not approved, and they don't wanna pay 3,000, which I would say I wouldn't want to either, they can have an alternative option now through Mark Cuban's Cost Plus Pharmacy.

Speaker 2 27:57

Celebrity. We have another celebrity mention.

Speaker 27:58

I know. We're talking about Trump- and Mark Cuban and everything. Now, this is interesting because you know they hate each other.

Speaker 2 28:04

Oh, no, I didn't know that.

Speaker 28:04

But they were together at a press conference the other day. Oh. 'Cause now they are joining up.

Speaker 2 28:08

No. Yeah. Yeah. Okay.

Speaker 28:09

Okay. So I think, and again, I hate politics, I think they're on the other end of the political spectrum from each other. They've like, I don't know, had little spats before. That's hilarious. I think it's so funny- Yeah when guys get into little cat spats.

Speaker 2 28:20

Yeah.

Speaker 28:20

Um, but anyways, the, recently in a press conference Mark Cuban's Cost Plus Pharmacy and Trump RX, somehow they're like joining up or something- Mm-hmm. Okay to try to make costs better for patients. So Mark Cuban's Cost Plus Pharmacy, the idea with this, and if y'all don't know him, he was from Shark Tank.

Speaker 2 28:36

Mm-hmm. And- Well, he owns the Mavs.

Speaker 28:37

Well, I- Yeah you know I'm not a sports girl.

Speaker 2 28:39

Yeah. I, I mean, that's why I know him- I, yes. growing up here. Yeah. Yeah. Okay.

Speaker 28:43

Um, and so his business idea- Mm-hmm was, hey, with pharmacies, it's okay to make some profit, but let's be transparent about our profit. Mm-hmm. And so he just says, "Look, we're just gonna take the cost of the medication, mark it up 15%, that'll be our profit. We're being transparent."

Speaker 2 29:00

Mm-hmm.

Speaker 29:00

And so that's been great. So I've been checking their website for fertility medications- Mm-hmm for a long time. And they did get daily Lupron. Mm-hmm. So not Depo-Lupron. Depo-Lupron is where it lasts one shot for the whole month. They don't have that yet, or I mean, hopefully it'll be on there soon. Yeah. But it's not as of May of 2026. Um, but they have the daily Lupron, um, kit. A lot of people call this the two-week kit, and it really is equivalent. You can take a shot every single day and still get the hormone suppression that you need. Um, you do need to get... 'Cause each one is only two weeks, you've gotta get multiple to cover that two-month period. But it's somewhere around, I wanna say $80- Mm-hmm or something like that. And so that would still be a lot cheaper than having to do the 3,000 per shot for two months. Um, so that can be an alternative, but I... It still sucks 'cause you have to take an injection every day.

Speaker 2 29:49

I

Speaker 29:49

know. It's a teeny one, but yeah.

Speaker 2 29:50

I wonder if Orilissa's on there.

Speaker 29:53

I don't think so, 'cause I think- Mm-hmm I had looked it for that one that- Yeah. But you know what? It's probably one of those things you have to check every week for. Yeah. I, I think so much- Yeah is happening so fast. Hopefully it'll be- Yeah on there soon. Yeah. So- But Orilissa would be a nice pill.

Speaker 2 30:03

Yeah. Yeah. Orilissa is the oral medication- Yeah kind of version that does the same thing. And yes, a lot of the studies were done with Lupron, right, the injectable one. But I will say in my clinical experience- Mm-hmm I s- visually see- Mm-hmm such improvements- Mm-hmm with my patients that have been on Orilissa, even more than I see with my patients- Really? on Depo Lupron. Oh, wow. Yes, it is crazy. Wow. I have been so impressed with how much I've seen endometriomas shrink-

Speaker 30:29

Ooh

Speaker 2 30:29

fibroids shrink. Great. And like sometimes I have patients on Lupron for two months, and I come back, I'm like, "Your fibroids look bigger to me." Oh,

Speaker 30:37

no. It just doesn't make any sense. Yes. You know? Yeah, yeah. Well, it is interesting you bring that up. One thing that one of my recent patients taught me- Mm-hmm is maybe you should be periodically checking the suppression levels- Mm-hmm on Depo Lupron. I, in past years, had always seen it work. Mm-hmm. I, I had never seen anyone break through the suppression. Um, but I have a patient recently who told me, "Look, I've tried this protocol with many different doctors. I always break through." Mm-hmm. "So would you mind just checking some labs on me periodically?" I said, "Sure, I don't mind. It's just blood work, right?" And sure enough, she was taking her medication. She kept breaking through the Depo- Mm-hmm Lupron and the, and the Letrozole. And so we ended up having to add Orilissa. Mm-hmm. And, uh, we... I mean, really, she was having to add a lot of stuff- Yeah to, to keep her suppressed. Um, and then it made me realize that, gosh, you know, I know that's not common to break through. Yeah. But maybe- Very rare. Very rare. Yeah. Yeah. And so kind of what I've been doing now with my patients moving forward is, is just periodically spot checking the suppression and just making sure it is- Yeah functioning properly.

Speaker 2 31:32

And we should say, you should feel reassured that that was not done in the studies. They weren't-

Speaker 31:36

Yeah

Speaker 2 31:36

they weren't checking- Yeah the hormone levels. Yeah,

Speaker 31:38

yeah.

Speaker 2 31:39

Don't worry if you're not getting that done. Yeah,

Speaker 31:40

yeah, yeah. Okay, perfect. Anything else you can think of that- No in terms of good advice?

Speaker 2 31:46

No.

Speaker 31:47

No?

Speaker 2 31:47

All right. Yeah. Get yourself a Workin.

Speaker 31:48

That's right. That's right. Did I say it right? You could be like, "Go to my affiliate link." No, I'm just kidding. I don't have that. Okay, perfect. Well, if you guys would be so kind, we would really appreciate a positive review, either on the podcast platform or our YouTube platform, or even on our Peak Fertility private practice page. We really appreciate the positive feedback that we hear from you guys, and we will see you all next week.

Speaker 2 32:13

Bye.

Speaker 32:13

Bye.